Download This Exam must be signed off by an MD or DO

SMCCCD Pre-Participation Sports Screening
This is not a substitute for a regular physical exam by your family doctor
Print Last Name ___________________________ Print First Name __________________ G# __________________ Sport ______
This Exam must be signed off by an MD or DO
Exams signed off by any other health care professional will not be accepted!
Students complete page 1 and 2 of this sports screening exam. All questions must be answered.
MD or DO must complete and sign page 3 of this sports screening exam.
1.
Yes
Yes
Yes
FAMILY MEDICAL HISTORY: Check “Yes” or “No” for all questions and explain all “Yes” responses in the space provided.
No Has anyone in your family ever died for no apparent reason? Relationship to you: ________________
No Has any family member/blood relative died of heart problems or of sudden death before age 50? Relationship to you ____
No Does anyone in your family have any heart problems, conditions (i.e. hypertrophic cardiomyopathy, dilated
cardiomyopathy, Long QT syndrome, Marfans’ syndrome, Cardiac Arrythmias) or has had heart surgery? Explain
2. ATHLETE’S MEDICAL HISTORY: : Check “Yes” or “No” for all questions and explain all “Yes” responses in the space provided.
When was your last physical exam that included blood pressure and a doctor listening to your heart & lungs? Date ______________
Yes No Have you ever had a medical illness, injury, or surgery that kept you from participating in practice or competition?
If Yes, explain: ________________________________________________________________________________________
Injury/Illness/Surgery was: ___________________________ Year_____Time missed: Days ___ Weeks ____Months ______
Yes No Were you born without or are you missing any of the following? ___ Kidney ___ Eye ___ Testicle ___ Other Organ
Yes No Are you allergic to: ___ Foods
_____ Stinging Insects _____ Environmental Agents/Pollen ____ Medication ________
Yes No Have you ever had to stay overnight in the hospital as a patient? Explain ________________________________________
Yes No Have you ever had any surgery for any medical condition? Explain _____________________________________________
Yes
Yes
Yes
Yes
Yes
No
No
No
No
Have you ever passed out or nearly passed out during exercise? Why? __ Medical Illness ___Conditioning __ Heat
Have you ever passed out or nearly passed out after exercise? Why? ___ Medical Illness ___Conditioning ___ Heat
Do you get more easily tired or fatiqued than your teammates during or after exercise? __ Med Illness __ Cond. __Heat
Have you ever had chest discomfort, pain or pressure during exercise? ___Mild Exercise _ Moderate Ex. ___ Strenous Ex
Has a doctor ever asked that you complete, or have you had, any of the following tests:
No
Test
Requested Completed Year For what reason?
X-Ray
MRI
CT Scan
Bone Scan
EMG (Nerve Test)
EKG (Heart test)
Stress EKG
Echocardiogram
Stress Echocardiogram
Halter Monitor
Yes
No
Medication/Supplement
Use
Name of
Medication
Reason/Condition
Name of Medication
Reason/Condition
Over-the-counter
Medications
Prescription Medications
Prescribed Creams/Ointment
Inhalers
Supplements for Weight Gain
Supplements for Weight Loss
Anabolic Steroids/HGH
Yes No Do you use or have you ever used recreational drugs? ___ Daily ___1x/week ___< 1x/week ___1x/month
Yes No Do you or have you ever consumed alcoholic drinks? ___ Daily ___ 1x/week ___<1x/week ___ 1x/month
Yes No Do you use tobacco? ___ Cigarettes ___Cigars ___ Smokeless Dip/Chew __Daily __1x/wk __<1x/wk __1x/mo.
San Mateo County Community College District - Updated 6/1/15
Page 1 of 4
Print Last Name __________________________Print First Name _______________G# __________________ Sport ___________
YES
NO
WOMEN ONLY
Have you been pregnant?
Are you pregnant now?
Date of first menstrual cycle
Longest time between periods
No periods since:
Menstrual irregularity / cramps
Are you taking Birth Control Pills
Year(s)
How many months?
Month _____ Year _____
Days _____ Months _____
Month _____ Year _____
Medication ________________________
2a. ATHLETE’S MEDICAL HISTORY – Have you ever had any of the following symptoms?
Yes No Year
Symptoms
Yes No Year
Symptoms
Dizzyness
Chest Pain
Fainting/Near Fainting
Shortness of Breath
Chest Tightness/Pressure
Wheezing
Irregular Heart Beats
Headaches
Abdominal Pain
Heart Skips Beats
2b. ATHLETE’S MEDICAL HISTORY – Have you ever had any of the following conditions?
Yes No Year
Condition
Yes
No Year
Condition
Rhumatic Fever
Asthma / Exercise Induced Asthma
Mononucleosis
Bronchitis
Jaundice
Pneumonia
Cancer
Pneumothorax
Kidney Disease
Thyroid Disease
Heart Murmur
Thyroid Disease
Cardiomyopathy
Marfan’s Syndrome
Heat Cramps/Illness
Sickle Cell: Disease ___ Trait ___
Dehydration
Heart Infection - Myocarditis
Heat Exhaustion/Stroke
Hemophilia
Anemia
Crohn’s Disease
High Blood Pressure
Bladder/Bowel problems
HIV ___
Aids ___
Anorexia/Bulimia
High Cholesterol
Ulcers
Diabetes: Type 1 __ Type 2 __
Apendicitis/Apendectomy
Blood Sugar: High ___ Low ___
Hernia
Hepatitis: A ___ B ___ C ___
Impetigo
Herpes Zoster
Herpes Simplex (cold sores)
Tinea Corporis (ringworm)
Tinea Cruris (jock itch)
Tinea Pedis (athletes foot)
Folliculitis
MRSA
Visual Impairment
Hearing Impairment
Concussion or Knocked Out
Migraine Headaches
Epilepsy
Seizures
San Mateo County Community College District - Updated 6/1/15
Page 2 of 4
Print Last Name ______________________________ Print First Name ________________ G# __________________ Sport _____
YES
NO
Don’t Know
IMMUNIZATION RECORD Year
Tetanus
Hepatitis A
Hepatitis B
Please list all medical illness or conditions that kept you from participating in any practice or competition, what year,
time lost, and outcome:
Condition
Year
Time Lost
Outcome
3. ATHLETE’S MUSCULOSKELETAL HISTORY: Have you ever had any of the following?
Yes No Year
Injury
Yes
No Year
Injury
Muscle Strain/Pull
Head Injury
Ligament Sprain/Injury
Neck Pain/Injury
Deep Bruise/Contusion
Upper Back Pain/Injury
Fracture
Lower Back Pain/Injury
Stress Fracture
Rib or Chest Pain/Injury
Nerve Injury/Stinger
Shoulder Pain/Injury
Meniscus Injury
Elbow Pain/Injury
Cartilage Injury
Forearm Pain/Injury
Labral Injury
Wrist Pain/Injury
Tendonitis/Tendinopathy
Hand Pain/Injury
Shin Splints
Finger Pain/Injury
Thumb Pain/Injury
Surgery
Hip Pain/Injury
Numbness due to injury
Thigh Pain/Injury
Weakness due to injury
Knee Pain/Injury
Lower Leg Pain/Injury
Crutches
Ankle Pain/Injury
Splint/Sling
Foot Pain/Injury
Brace
Toe Pain/Injury
Please list all injuries that kept you from participating in any practice or any competition?
Injury
Year
Time Lost
Outcome
I certify that all the information I have completed regarding Family Medical History, Athlete’s Medical History,
Medication/Supplement Use, Immunization Record, and Musculoskeletal History is complete and accurate to the best of
my knowledge.
Athlete’s Signature _____________________________________ Date____________________
Parent’s Signature (if athlete is a minor under 18 years) ______________________________ Date________
San Mateo County Community College District - Updated 6/1/15
Page 3 of 4
Print Last Name: ___________________________ First Name_____________________ G#____________________
Sport:______________
MD or DO must certify and sign off this section. Doctor, please check each item with your finding and provide a
final disposition at the bottom of the form.
4. MEDICAL EXAMINATION
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
Check each item giving details in space to right if abnormal or noteworthy.
Medical Examination
Normal
Blood Pressure (Seated) Systolic_______/_______ Diastolic
Resting Heart Rate (required) BPM:
Eye Test (required) Left Eye: 20/
Right Eye: 20/
Vision tested with
Height: _____’ _____”
Weight:_______
General Appearance (fitness, body fat)
HEENT (pupils, ears, eyes, nose, mouth, teeth, throat)
Chest (chest wall and breath sounds)
Cardiac auscultation supine and standing (murmur)
Cardiac (Pulses and rhythm)
Abdomen (liver, spleen, masses)
Skin (rash, jaundice)
Neurologic (CNS, DTR’s, sensations)
Geniturinary (male only: hernia, testes)
BMI: ________ or
% BF: ____________
(Optional)
Abnormal
Contact Lenses
Glasses
5. MUSCULOSKELETAL EXAMINATION: Check each item giving details in space to right if abnormal or noteworthy.
Musculoskeletal Exam: (Grade abnormal joint laxity tests on a 0-3+ scale)
1. Spine (deformity, tenderness, motion, strength, stability)
a. Cervical (facet dysfunction, disk injury, radiculopathy, stingers)
b. Thoracic (kyphosis, scoliosis)
c. Lumbar (spondylolysis, spondylolisthesis, facet dysfunction, disk injury)
2. Upper Extremity (deformity, tenderness, motion, strength, stability)
a. AC/ SC Joint/Clavicle (AC separation, clavicle dislocation/instabillity)
b. Shoulder (rotator cuff, labrum, instability, impingement)
c. Elbow (UCL tears, tendonitis, loose bodies, Little League elbow)
d. Wrist (carpal tunnel, tendinitis, instability)
e. Hand
f. Thumb (De Quervain’s, instability, tenderness, motion)
g. Fingers (Mallet or Jersey Finger, Swan Neck or Boutineer Deformity
3. Lower Extremity (deformity, tenderness, motion, strength, stability)
a. Hip (deformity, joint pain, range of motion, hip flexors, labrum)
b. Leg (Hamstrings, Quadriceps)
c. Knee (MCL, LCL, ACL, PCL, Meniscus)
d. Lower leg (MTSS, Achilles Tendon)
e. Ankle (talar tilt, anterior drawer)
f. Foot (supination, pronation, pes cavus, pes planus)
g. Toes (hallux valgus, hammer toes, bunions)
Finding/Problems
Normal
Abnormal
Recommendations (Prevention/Treatment)
1
2
3
MEDICAL AND MUSCULOSKELETAL DISPOSITION
_______ Cleared for collision/contact/non-contact sports
_______ Conditional Participation, limited to: _____________________________________________________________________
_______ No participation until:__________________________________________________________________________________
_______ No participation in any sport because of:___________________________________________________________________
Physician’s Signature Required: ___________________________________________ Date: :_____/______/______
_
Print Physician’s Name:______________________________________________________________
MD
DO Please check
M.D. Office Stamp Required
Physician’s Phone if not on office stamp: (
)
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San Mateo County Community College District - Updated 6/1/15
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